| Lost Lake Optical Company | |
|
5240 Shady Island Cir Mound MN 55364-9222 | |
| (612) 670-8887 | |
| (952) 474-1933 |
| Full Name | Lost Lake Optical Company |
|---|---|
| Speciality | Clinic/center |
| Location | 5240 Shady Island Cir, Mound, Minnesota |
| Authorized Official Name and Position | Jay B. Petersen (OWNER) |
| Authorized Official Contact | 6126708887 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Lost Lake Optical Company 5240 Shady Island Cir Mound MN 55364-9222 Ph: (612) 670-8887 | Lost Lake Optical Company 5240 Shady Island Cir Mound MN 55364-9222 Ph: (612) 670-8887 |
| NPI Number | 1003434622 |
|---|---|
| Provider Enumeration Date | 07/09/2020 |
| Last Update Date | 09/04/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003434622 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |